Part­way across the qual­ity chasm

Providers im­prove per­for­mance, but good mea­sure­ment still lack­ing

Modern Healthcare - - COVER STORY - Mau­reen McKin­ney

Much has changed in the years since the In­sti­tute of Medicine pub­lished To Err is Hu­man and Cross­ing the Qual­ity

Chasm, com­pan­ion re­ports re­leased in 1999 and 2001 that sounded the alarm about high rates of ad­verse events and the ur­gent need to adopt proven best prac­tices in health­care.

Govern­ment agen­cies have ramped up im­prove­ment ef­forts through pub­lic re­port­ing man­dates, demon­stra­tion projects, pay­ment in­cen­tives and other pro­grams. And many hos­pi­tals and health sys­tems have un­der­taken large-scale ini­tia­tives aimed at low­er­ing rates of hos­pi­ta­lac­quired con­di­tions, curb­ing read­mis­sions and en­gag­ing pa­tients in their care, all while im­ple­ment­ing in­ter­ven­tions to re­design care pro­cesses, im­prove cul­ture and cre­ate high-re­li­a­bil­ity sys­tems.

Ex­perts say those ef­forts have led to some sig­nif­i­cant im­prove­ments, in­clud­ing re­cent strides in re­duc­ing rates of some types of health­care-as­so­ci­ated in­fec­tions and im­prov­ing co­or­di­na­tion among providers. But there is still plenty of work to be done.

“I’m en­cour­aged by the aware­ness and the progress over the last few years, but I’m also dis­mayed by how slow it has been,” said Ju­lianne Mo­rath, CEO of the Sacra­mento, Calif.-based Hos­pi­tal Qual­ity In­sti­tute, a new not-for-profit formed by the Cal­i­for­nia Hos­pi­tal As­so­ci­a­tion and sev­eral re­gional hos­pi­tal groups. “We’re still harm­ing peo­ple through pres­sure ul­cers, falls, poor hand hy­giene—less than we were be­fore, but we’re not close to zero yet.”

She pointed to par­tic­u­lar ar­eas of suc­cess, in­clud­ing hos­pi­tals’ marked re­duc­tion in rates of cen­tral line-as­so­ci­ated blood­stream in­fec­tions.

“The prob­lem is that as we solve one is­sue, there are oth­ers that re­place it and they come in rapid suc­ces­sion,” Mo­rath said. “Our physi­cians and nurses need more el­e­gantly de­signed sys­tems with ac­ces­si­ble, in­ter­pretable data.”

In com­pan­ion re­ports on health­care qual­ity and dis­par­i­ties, re­leased in May, the Agency for Health­care Re­search and Qual­ity found that qual­ity is con­tin­u­ing a slow but steady up­ward climb, while health­care dis­par­i­ties showed lit­tle to no signs of im­prove­ment and ac­cess to care wors­ened.

Over­all me­dian qual­ity im­proved 3.2% across the health­care sys­tem, just slightly above the rate of change re­ported in pre­vi­ous years, ac­cord­ing to the an­nual AHRQ re­ports, now in their 10th year, which draw in­for­ma­tion from a slew of sources, in­clud­ing ad­min­is­tra­tive data, pa­tient sur­veys, and home health and hospice re­ports. The over­all rate of im­prove­ment in last year’s re­port, for in­stance, was 2.5%.

“We have a long way to go, but when you step back and look at the progress we’ve made over the last 10 years, it does add up,” said Dr. Ernest Moy, med­i­cal of­fi­cer in AHRQ’s Cen­ter for Qual­ity Im­prove­ment and Pa­tient Safety. “We can look back and be proud that qual­ity has con­sis­tently and per­sis­tently im­proved each year.”

Moy said he ex­pects even big­ger jumps in qual­ity—and long-awaited im­prove­ments in racial, eth­nic and so­cioe­co­nomic dis­par­i­ties—in 2014, with the im­ple­men­ta­tion of ex­panded cov­er­age and state in­sur­ance ex­changes un­der the Pa­tient Pro­tec­tion and Af­ford­able Care Act.

Th­ese lat­est AHRQ re­ports draw from data through 2009, with some from 2010, a pe­riod Moy said should serve as a base­line mea­sure of the state of health­care qual­ity, ac­cess and eq­uity be­fore the ear­li­est pro­vi­sions of the ACA kicked in.

“I’m def­i­nitely hope­ful,” Moy said of the prospects for fu­ture qual­ity gains. “We’re fi­nally ad­dress­ing the is­sue of ac­cess in a big way, and I’m look­ing for­ward to good news.”

But au­thors of a re­cent re­port from the Robert Wood John­son Foun­da­tion ar­gued

that ef­forts to im­prove qual­ity and pa­tient safety will fal­ter un­less more at­ten­tion is paid to im­prov­ing per­for­mance mea­sure­ment. The 31-page re­port, re­leased May 21, in­cluded seven pol­icy rec­om­men­da­tions, such as mov­ing ag­gres­sively from process to out­comes mea­sures, mea­sur­ing qual­ity at the or­ga­ni­za­tional level in­stead of the clin­i­cian level, in­vest­ing in the science of mea­sure­ment de­vel­op­ment and in­cor­po­rat­ing more pa­tient-re­ported out­comes.

“It’s a good time to re­flect and take a crit­i­cal look at the mea­sure­ment en­ter­prise,” said Dr. Har­lan Krumholz, a pro­fes­sor of car­di­ol­ogy and health pol­icy at Yale Univer­sity, New Haven, Conn. Krumholz co-au­thored the re­port with Dr. Peter Pronovost, di­rec­tor of the Arm­strong In­sti­tute for Pa­tient Safety and Qual­ity at Johns Hop­kins Univer­sity, Bal­ti­more, and Dr. Robert Beren­son, a se­nior fel­low at the Wash­ing­ton-based Ur­ban In­sti­tute.

Krumholz said the pol­icy rec­om­men­da­tions listed in the re­port are “vi­tal” for bol­ster­ing con­tin­ued ef­forts to im­prove qual­ity and safety. The au­thors also called for the for­ma­tion of a sin­gle en­tity tasked with defin­ing mea­sure­ment and re­port­ing stan­dards, sim­i­lar to the role the Se­cu­ri­ties and Ex­change Com­mis­sion serves for the re­port­ing of cor­po­rate fi­nan­cial data.

“We’re mak­ing so many changes to health­care de­liv­ery, and we need to know how our work is im­pact­ing pa­tients,” he said. “With­out the abil­ity to as­sess where we stand, I think we’re go­ing to be in the dark about what to do next.”

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